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Tuesday, April 03, 2012

I just finished reading The Scalpel and the Silver Bear, the story of the first Navajo woman surgeon. In her book, Lori Alvord describes how she integrated her Navajo spiritual beliefs into her surgical practice. One incident really challenged her determination to treat all her patients with respect, dignity, and cultural sensitivity: A young girl came into her hospital in extreme pain. Every symptom pointed to acute appendicitis. But the girl's grandmother, the key decision-maker in the family and in Navajo culture, refused. Dr. Alvord describes her feelings at that moment:

I could see both sides of the story. One side--the trained medical practitioner, who fathoms the body's mysteries as a detective directs a beam of light into a dark room to look for clues about the source of physical disharmony--said, Roll her into the OR now! But the Navajo part of me, who had once been a little girl, could see the inappropriateness of interfering. Navajo eyes warned: The beauty of the body would be disturbed. A surgical knife would defile an intact, miniature universe, with rules and systems that evolved naturally over millennia. I could see the sacredness of that body, how all its many parts are one harmonic system.

She knew that this grandmother's fear of white, western medicine went back to the grandmother's firsthand experience witnessing Navajo children being forced into white boarding schools, back (only a few decades) to when the Bill of Rights and religious freedom did not apply to Native Americans, back even farther into the strong cultural memory of the Long Walk of 1863 that displaced and killed thousands of Navajos.

While Dr. Alvord was trying to find a way to meet this grandmother on her own ground and persuade--but not force--her to consent to the girl's surgery, the pressure was rising. Hospital social workers were seeking a legal court order to override the family's opposition. Even though this would save the girl's life, Dr. Alvord wanted to find a way to preserve the family's dignity and autonomy. She decided to give the grandmother control. "I told Bernice that the decision was hers to make. It was something I had begun to tell patients more and more, a show of respect that I believed would be empowering; that they alone, not the doctors or anyone else, control the fate of their bodies," she writes. More relatives arrives, more time passed, and the court order was closer to completion. "Although the court order might save the girl's life, it could also be a cultural disaster, and it would make a liar and an enemy of me."

At the end of the day--the girl still sick, the hospital staff in suspense, the grandmother still unrelenting--Dr. Alvord had a quiet conversation with the girl's father, letting him know that the decision was still his, but that it needed to be made soon before it was too late. Soon after, word came via her pager that the consent forms were signed. She rushed in and removed the infected appendix.

This small drama illuminates a larger truth about meeting patients on their terms, not the provider's or the hospital's. Women who wish to give birth outside the norm--whether an unmedicated hospital birth with intermittent monitoring and no IV access, a planned home birth, or a vaginal breech birth--often face ridicule, hostility, and threats of punishment. These tensions are particularly strong during hospital transfers or when a woman actively disagrees with her care provider about her plan of care.

Earlier this year, Australian Medical Association WA president proposed criminal penalties for mothers who have high-risk home births. "We're talking about when people choose to proceed with a homebirth when it's clear that there is an extreme danger to the baby and particularly when that's encouraged by people who should know better," Dr. Dave Mountain said. Michelle Mears, spokeswoman for Homebirth Australia, remarked, "To suggest that traumatised women who are refugees from obstetric medical care and their care providers should be charged with a crime is a proposal to move back to the dark ages." In February, the Attorney General struck down that proposal, so homebirth related deaths will not be part of the proposed fetal homicide laws in WA. But this will not erase tensions over women's childbirth choices.

I understand why some hospital staff might struggle to understand women's desire for a home birth (or a vaginal breech birth, or even an unmedicated birth). But this doesn't negate the very real fears, desires, and values that women bring to their births. Punishing women for insisting that their own values and wishes are important is the wrong approach. It will only further the divide between home and hospital advocates and push home birth women and midwives deeper underground, deeper into riskier territories. Meeting women where they stand, respecting their values and beliefs, and always upholding their autonomy--these actions are what are when obstetric conflict arises. Not punishment or threats.

A surgeon will see a necessary appendectomy as a no-brainer: Do the surgery and live. Don't do it and die. Likewise, for some people, a cesarean section is a minor event and causes little heartache. It might even be seen as preferable to a "bloody, messy" vaginal birth. But to others, a cesarean section means a devastating loss of bodily integrity, weeks or months of debilitating pain, and a feeling of failure or incompleteness as a mother. The solution isn't to legislate one of these worldviews and ban the other. The solution is to respect patients' wishes and values, to treat them with dignity, and to uphold their autonomy. When Dr. Alvord did this with the little girl and her family, she acted as a true healer, not just as a physician.

8 comments:

I understand respecting autonomy. However when it comes to already born children I don't think society should always defer to the parents. Every year there are at least a couple of deaths due to parents denying their children medical care in favor of prayer or faith healing.

I understand there was a court order pending in your example, but what if there hadn't been. Would have been acceptable for the family to refuse surgery and let the girl die?

Well you are getting into an area of the rights of faith (and personal choice) vs. the right of government. That isn't just about childbirth, but about every aspect of life. You're never going to "solve" that completely because for a good percentage of the world religion/faith comes before government. How can you tell more than half of the world they have to play by your rules? That's a complicated subject. I believe the point of this story shows this divide well. Meaning by trying to save a few babies that unfortunately die b/c of poor parental decisions, you jeopardize the rights of MANY who do make good decisions. Monitoring how people choose to give birth, though it may save a few babies, threatens the well-being of far more. It also causes a great division between people an the government. This story accurately describes this problem on many levels:The grandmother was under the rules of a government who slaughtered and enslaved many of her people. And now she's supposed to trust the life of her precious grand daughter to that same government? Of course she would not. THAT would be irresponsible parenting. You rightfully do not trust someone or something that tried to kill you or your loved ones.If government is allowed to hyper monitor births that also means it has that much more right into our individual lives--making decisions for us that may not be theirs to make. When we invite the government to take more power than it has over our daily lives it also has consequences and each one needs to be weighed against the possible benefit.

Sounds really interesting. It reminded me of another book you might enjoy (if you haven't already read it) called The Spirit Catches You and You Fall Down about a Hmong family navigating medical care for their child's epilepsy in California. Always good to get outside one's natural perspective. Thanks for covering this!

Thank you for this. I'm a homebirther in Illinois and I and many of my friends have been punished for our birth choices (I had a mean nurse at my hospital transfer for #1 and was kicked out of obstetric care for #2, one friend's healthy baby was held captive in the NICU for 5 days after a transfer, another friend had DCFS called on her after she transferred to get a tear repaired). It's done nothing but make me want to stay away from the medical model, and give me weeks of anxiety over how they'd try to ruin my family if something with wrong.